Setting

Patients

77 adolescents who were 12.5–20 years of age (mean age 16 y, 58% girls, 92% white), had type 1 diabetes (mean duration 8.4
y) with no other health problems except for treated hypothyroidism, had been treated with insulin for ≥1 year, had haemoglobin
A1c (HbA1c) concentration of 7–14%, had had no severe hypoglycaemic events in the previous 6 months, and were in an appropriate school
grade for their age (within 1 year). Follow up was 100%.

Main results

HbA1c concentrations decreased in both groups after 6 months; the decrease was greater for CST than for intensive management alone
(HbA1c concentration 7.8% v 8.3%, p=0.02). Hypoglycaemic events were similar in both groups (23 v 22 episodes for CST and intensive management alone, respectively; p=0.6). The groups did not differ in the number of adolescents
who were overweight after 6 months (12% for CST and 20% for intensive management alone, p=0.85). General self efficacy was
greater in the CST group than in the intensive management alone group at 6 months (mean SEDS score 28.9 v 26.1, p=0.01). CST led to greater improvement on quality of life subscales than did intensive management alone (mean score
difference for disease impact 6.3 v 2.5, p=0.01; mean score difference for worry 3.3 v 0.1, p=0.02). No difference between groups existed for depression.

Conclusions

In adolescents with type 1 diabetes mellitus, the addition of a coping skills training programme to intensive diabetes management
led to improvement in haemoglobin A1c concentration, general self efficacy, and some quality of life measures. Coping skills training did not reduce hypoglycaemic
events, number of adolescents who were overweight, or depression.

Commentary

Although the Diabetes Control and Complications Trial showed that improved glycaemic control delays the onset and slows the
progression of severe microvascular complications of diabetes,1 improving glycaemic control remains a daunting problem for many people with type 1 diabetes mellitus. Often, the demanding
lifestyle changes and rigorous self management behaviours are difficult to implement. In the first well designed randomised
controlled trial that tests the effects of a behavioural intervention for adolescents receiving intensive diabetes treatment,
the findings of Grey et al have important implications for the treatment of type 1 diabetes. They show that CST improves both glycaemic and quality
of life outcomes in adolescents, a group that often has difficulty reaching glycaemic goals.

This study shows the importance of teaching adolescents how to deal with the demands of a chronic illness. CST, a nurse taught
intervention that incorporates behavioural strategies with coping skills and cognitive approaches, goes beyond simply offering
support and knowledge. Adolescents learnt to deal with difficult situations, such as managing food decisions with friends,
by role playing and observing the nurse model appropriate coping behaviours. This innovative approach is a valuable addition
to diabetes treatment.

Because only a small number of adolescents from minority groups were studied, the effectiveness of CST for non-white adolescents
is unclear. Although CST is designed for adolescents, the synergistic effect between CST and intensive treatment suggests
that a similar behavioural approach should be developed and tested in adults with type 1 and type 2 diabetes, including those
from non-white ethnic groups.

Grey et al describe CST as a relatively inexpensive, brief intervention. Although the actual costs of CST were not reported, intensive
treatment, with its improvement in glycaemic control, leads to large healthcare cost savings over time through slowed progression
of complications.2 Detailed investigation into further cost savings realised by CST, if any, may lead to wider use by healthcare organisations
and providers.